Orthodox Jewish groups are challenging a New York regulation requiring those who perform ritual circumcisions to present parents with a consent form.

Lawyer Shay Dvoretzky told a federal judge on Tuesday that the regulation requires the mohelim performing the circumcisions to convey the city’s perspective, the New York Times reports. “That lies at the heart of First Amendment protection,” Dvoretzky said.

The regulation requires the consent form when the ritual the circumciser uses his mouth to remove blood from the wound, the Times says. Michelle Goldberg-Cahn, a lawyer for the city, argued the regulation is a health matter. She says the practice may have caused 11 herpes infections that led to the deaths of two babies and brain damage in at least two others.

U.S. District Judge Naomi Reice Buchwald directed her “sharpest inquiries” at Dvoretzky, the story says. She asked him for his views on a hypothetical in which a religious group amputates left pinkie fingers at birth. Dvoretzky said the city could regulate the practice if it caused immediate, serious harm.